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APPLICATION FOR SANITATION PERMIT Permit No. --1a- .- -� (Complete in Duplicate) ` • -Date Issued Application is hereby made to the San Joagdin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with ty Ordinance No. 549, JOB ADDRESS AND LOCATjCN__ —------ , ttirr �0-LQ - ,- � y Owner's Name-------------r '----- ---- r --------------------------------------------------------. Phone.1/ ---- ------- --•---- Address ----------------------------------- -------------------------------------------------------------------------------------------------------- Contractor's Name----------------------016 ------------------•-------'_-_-------------_-=='----------------------------------- - Phone.---------------------------------- F Installation will serve: Residence [g--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' • j ._d 3"V-7 r Number of living units: .-----__ Number of bedrooms - -_-_ Number-'of baths._� yLot size__-_�1a---- -_ - --_-----_-_______---_--.-._ Water Supply: Public system ❑ Community system ❑ Private Ea�Dpth to Water Table -------- ft. l Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ©f ay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No EK New Construction- Yes D`_No ❑ FHA/VA: Yes ❑ No P--"— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_- - --------_Distance from foundation_-.JG--_-.____.Material__-Cal- ----- No. of compartments --Size-A"_ � 4_3_-------Liquid depth-- -�y-------------------Capacity-,--` t C; Disposal Field: Distance from nearest well.--5,VV--- --Distance from foundation---Y+�-_'_---_-.--Distance to nearest lot line_._--------_- Number of lines-------'_---------- -------------Length of each line----- :---.--------Width of trench---- -«--_---------------- Type of filter mate ria l__ = 1_---...---Depth"of filter material_-----!-�-_-------Total length-----------L'-ts.�----------------- 1 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_----.------_-_-_ ❑ Number of pits----------------------Lining material------------------------Size: Diameter—--------------------.Depth--- --------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------.Lini'ng material-----_---------------_-_--____----_-. q ❑ Size: Diameter--------------------------------------Depth------- ----------------l-------.-- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest we]------------------------------------------------Distance from nearesf building----___._____._-------__----------------. ❑ Distance to nearest lot line------ - -------------------------------------------------------------------------------------------------------- --------------------------- Remodelingand/or repairing (describe):---------------------- -------------------------------------------------------- ---------------•----------------------•------------------------------ + ----------------------- --------------------------------•-----------------------------------'---------------------•------------ -----------------------------------------------------------------------------------•------------------------------- l ---------------------------------------------------•------------------------------------ •----------------------------------------------------------------------------------------------------- -------------------------- I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laV, and-0,rules and regulationA of t le San Joaquin Local Health District. - (Signed) !/ ---- -------- --------------------------------------------------------------------(Owner and/or Contractor) By:-------------- •---- v -- Title --------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----� ------------- - -- DATE-- = I-------------------------- REVIEWEDBY-------------------------------------- --------------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------- Alterationsand/or recommendations-------------------------- ---------------------------------------------------------------------------•----••--------------------------- ------ - --------------------------•----•----------------------------------- --------------------------------------------------•------------------------------------------.._._.-----------•--...----•-----•-------------------------- ---------------------------------------------------------------------------------------------------------------------•----------------- --------------.---------------------------------------------------------------------- ---------------------------------------------- FINAL INSPECTION BY-------------- Date------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South.American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 F.P.CO. 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